Discontinuation and change are part of life. We all start and stop various activities. Jobs change, relationships change. So, too, may medical treatments, such as antidepressants that help many people navigate depression and anxiety. Planning changes in advance tends to make things easier and smoother. You may start a medication for treatment and discover that it’s not helping your particular medical issue. Or perhaps you’re having side effects. Or maybe your condition has improved, and you no longer need the drug. If so, working with your doctor to change or stop taking an antidepressant slowly may help you avoid uncomfortable symptoms known as discontinuation syndrome.

What is discontinuation syndrome?

Discontinuation syndrome can be a consequence of stopping certain types of antidepressants: selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs). You may have heard about this from a friend or on the news, or perhaps read a recent New York Times article on this topic. If you are taking an antidepressant, you may be concerned about your own response to stopping the medication.

Let’s clarify what the term means. Discontinuation syndrome describes a range of symptoms that may occur in patients taking SSRIs or SNRIs after stopping quickly. These can include:

nausea

feelings of vertigo

trouble sleeping

odd sensory symptoms, such as “pinging” feelings in the skin, or what some people describe as a “zapping” sensation in the brain

feeling anxious.

As many as one in five people who stop an antidepressant quickly may experience at least a mild version of these symptoms. Usually discontinuation syndrome occurs when a person has been taking medication for at least six weeks or longer. And it’s more likely to happen if you have been taking medication for a long time.

When people stop taking medication, some antidepressants leave the body quickly (short half-life), while others leave the body more slowly (long half-life). Discontinuation symptoms may occur in either case, especially if a drug is stopped abruptly.

Symptoms usually start two to four days after stopping the medicine. They usually go away after four to six weeks. In rare cases, they may last as long as a year.

What are SSRIs and SNRIs?

An SSRI is a type of antidepressant. Examples include fluoxetine (Prozac), paroxetine (Paxil), and sertraline (Zoloft). These drugs make a neurotransmitter called serotonin more available in the brain. Experts believe this helps reduce symptoms of depression and anxiety and regulate mood.

SNRIs are another type of antidepressant. Examples include duloxetine (Cymbalta) and venlafaxine (Effexor). These drugs work on two neurotransmitters: serotonin and norepinephrine.

These two classes of antidepressants are groundbreaking. Older antidepressants had many hard-to-tolerate side effects, including severe fatigue, dry mouth and eyes, and difficulty urinating. In contrast, SSRIs and SNRIs are generally well tolerated. Like all drugs, though, they do have side effects, including effects on sexual function, which can be difficult to talk about, but are important to tell your physician. Each drug is a little different, and an experienced psychiatrist can help people choose the best option for them.

We encourage patients to think broadly about treating depression. Treating depression with medicine can be very effective. Talk therapy, including cognitive behavioral therapy, also has been shown to be very helpful, as have exercise and social activities. Think about treatment for depression like a menu at a restaurant where you can choose foods from more than one column. Often, a combination of medicine and nondrug treatment maximizes the benefit of both.

What if you’re ready to stop taking an antidepressant?

Let’s suppose you have been on an SSRI like paroxetine for several years and having been working with a psychologist whom you really trust. Your depression is better and you feel ready to stop your medicine. To help you avoid discontinuation syndrome, work closely with the doctor who prescribes your medicine.

While some drugs can either be stopped or very quickly tapered, almost all SSRIs and SNRIs need to be slowly decreased. You may be instructed to drop the dose by small amounts each week, or perhaps every two weeks, or even every month. If you’ve been on a higher dose of medication, a taper may take as long as six months. It’s not worth rushing it because you don’t want to develop discontinuation symptoms. However, if you do, your doctor can increase the dose and then after a little while, you can try the taper again.

We have had patients tell us that physicians don’t want to start these antidepressants for fear of triggering discontinuation syndrome when it’s time to stop taking the medicine. But these are useful and safe medications for most people, and it’s worth exploring their potential carefully. Depression is a serious and common affliction that should be actively treated by all effective methods.

Christopher Bullock, MD, MFA, 1947–2018, was a psychiatrist, psychoanalyst, and writer. He loved Gary Snyder’s poetry; “all the junk that goes with being human” was a quote that inspired his life, his work, and his illness.

]]>https://www.health.harvard.edu/blog/discontinuation-syndrome-and-antidepressants-2019040416361/feed3216361https://www.facebook.com/sharer/sharer.php?u=https%3A%2F%2Fwww.health.harvard.edu%2Fblog%2Fdiscontinuation-syndrome-and-antidepressants-2019040416361]]>Post-hospital syndrome: Tips to keep yourself or a loved one healthy after hospitalizationhttps://www.health.harvard.edu/blog/post-hospital-syndrome-tips-to-keep-yourself-or-a-loved-one-healthy-after-hospitalization-2019012315830https://hhp-blog.s3.amazonaws.com/2019/04/GettyImages-1060711206.jpg2019-04-04 10:30:592019-04-04 14:30:59Chronic fatigue syndrome: Gradually figuring out what’s wronghttps://www.health.harvard.edu/blog/chronic-fatigue-syndrome-gradually-figuring-out-whats-wrong-2019111418224https://hhp-blog.s3.amazonaws.com/2019/04/GettyImages-1060711206.jpg2019-04-04 10:30:592019-04-04 14:30:59Ehlers-Danlos syndrome: A mystery solvedhttps://www.health.harvard.edu/blog/ehlers-danlos-syndrome-mystery-solved-2017080712122https://hhp-blog.s3.amazonaws.com/2019/04/GettyImages-1060711206.jpg2019-04-04 10:30:592019-04-04 14:30:59Women and pain: Disparities in experience and treatmenthttps://www.health.harvard.edu/blog/women-and-pain-disparities-in-experience-and-treatment-2017100912562https://hhp-blog.s3.amazonaws.com/2019/04/GettyImages-1060711206.jpg2019-04-04 10:30:592019-04-04 14:30:59What parents should know — and do — about young children and mobile deviceshttps://www.health.harvard.edu/blog/what-parents-should-know-and-do-about-young-children-and-mobile-devices-2017102412619https://hhp-blog.s3.amazonaws.com/2019/04/GettyImages-1060711206.jpg2019-04-04 10:30:592019-04-04 14:30:59https://hhp-blog.s3.amazonaws.com/2019/04/GettyImages-1060711206.jpgAn insider’s guide to a hospital stayhttps://www.health.harvard.edu/blog/an-insiders-guide-to-a-hospital-stay-2018071814266
https://www.health.harvard.edu/blog/an-insiders-guide-to-a-hospital-stay-2018071814266#commentsWed, 18 Jul 2018 14:30:20 +0000https://www.health.harvard.edu/blog/?p=14266No one wants to be have to go to a hospital, but there are times when it’s unavoidable. Having some advance knowledge about the hospital experience may help you feel more comfortable in the event you or someone you know has to go to the ER or be admitted.

Hopefully, you’ll never experience what it’s like to be an inpatient in the hospital. But even if it’s not you, it’s likely that someone — family member, good friend, colleague — will experience a hospital stay at some point. We want you to help you be as informed (and comfortable) as possible.

The emergency room

Although people sometimes use the emergency room for a routine doctor visit, it’s really a place for… emergencies. If you need to go to an emergency room, you’ll first be “triaged.” That means that based on your symptoms or type of injury, you will be assigned to a status that will determine how quickly you are seen and treated. Chest pain, a sudden severe headache, bleeding from a wound that doesn’t stop, shortness of breath: these are all emergencies, and these patients will be seen immediately for urgent evaluation. If you have a cold or a sore ankle, you’ll be assigned a less urgent spot, and may wait hours before being seen. Unless it really is a true emergency, it’s best to call your primary care provider first. She or he can help determine if in fact you need an emergent visit, and can call ahead and let the medical staff know that you’re on your way and what’s wrong. This may expedite your care.

Once you are checked in, you’ll start with an assessment by a nurse, and then a medical assistant may check your blood pressure and heart rate, as well as your temperature and pain level (“vital signs”). You may be assessed by a physician’s assistant (PA). These health care professionals will examine you and take a careful history, and will then “present” your situation to the emergency room “attending,” the senior physician in charge. He or she will likely check in with you as well, but most often, a PA or “house staff” (doctors in training who are often specializing in emergency medicine) will manage your care. Each person who enters your cubicle — and there may not be much privacy — should identify him/herself to you. The team will order and interpret any testing needed, treat your acute issue, and decide whether you need to be admitted or (hopefully) go home with a care plan and follow-up arranged. Never leave the emergency room unless you know exactly what to do if you feel worse or develop new symptoms.

Admission: A hospital sleep-over

If the team decides you are too ill to go home, you’ll stay at the hospital (be admitted).

An ICU stay is for patients who are unstable and need to be closely monitored. ICUs are busy places. Each patient has his/her own nurse. The medical team usually includes interns, residents, and fellows (doctors who have completed residency but are getting additional training). Less-experienced physicians are carefully supervised. There may be PAs or nurse practitioners on the team, and the senior staff physician (attending) has ultimate responsibility for your care. The team may call in specialists (consultants) to help determine your diagnosis and treatment.

If you are more stable/less sick, you’ll go to the “floor” with a similar team of health care professionals caring for you. Many hospitals have only private rooms, but not all. When you feel sick and vulnerable and are lying in a bed wearing a “johnnie” (hospital gown), a roommate is probably the last thing you want. You have the right to have your room be quiet, and if your roommate has visitors, they need to respect your comfort as well. Every day, you’ll have a nurse who is responsible for caring for you and other patients.

Both in the ICU and on the floor, a group of doctors and nurses will likely visit you early in the morning as they make “rounds,” checking on each patient and planning care for that day. Again, if you have a roommate, you’ll have no privacy during medical visits to your bedside. There is an unwritten “code of silence” but patient confidentiality is quickly sacrificed when you’re admitted.

Going home: Discharge from hospital

When you are ready to go home (be discharged), a member of the medical staff will review a care plan with you. This might include follow-up visits with your doctor or specialists, prescriptions, home care instructions, and (for some people) arrangements for a visiting nurse to help during your recovery. Don’t be afraid to ask questions, no matter how small or “silly” they might seem. Write down the answers or have a friend or family member write them down for you. You want to be sure you leave feeling a lot better, and empowered, than when you arrived.

Insider tips for your hospital stay

If time and your situation allow, bring reading material, phone chargers, and a list of all your medications when you go to the emergency room.

Make sure your primary care doctor stays informed during your stay, and gets written documentation when you are discharged.

Ask any and all questions. Use the nurse call button if you are in pain or need anything (for example, if you’re feeling worse, or need help using the bathroom).

Make sure the staff knows how to reach your family or health care proxy.

If you don’t already have a health care proxy in place, create one as soon as you finish reading this blog post. You want to have someone you trust understand your wishes for medical care should you become unable to express them yourself.

If any member of the medical staff says something that you don’t understand, ask for an explanation. It’s useful to repeat back what you have heard, so that you are sure you are clear on the explanation.

Although you sacrifice some of your own autonomy as a patient (you are vulnerable, feeling ill, lying in a bed), take what control you can. Ask each person who cares for you who he/she is, what role that person has, and to explain what is happening (for example, the purpose of any test or procedure).

There are often services available to help you during your stay, but you need to know about them. Most hospitals have a patient/family liaison who can guide you. For example, you can request a spiritual visit, a pain consult, or a nutritionist to help with your diet. Many hospitals have social workers who can help identify resources when it’s time to go home. Some aspects of care may not go as well as possible. Communication may be the biggest problem. Strong emotions such as fear, guilt about being sick, confusion, and anger are common. Your doctor recognizes what a tough experience this is, and it’s okay to share these emotions with your treatment team. Tending to your emotional health is a part of getting well.

]]>https://www.health.harvard.edu/blog/an-insiders-guide-to-a-hospital-stay-2018071814266/feed114266https://www.facebook.com/sharer/sharer.php?u=https%3A%2F%2Fwww.health.harvard.edu%2Fblog%2Fan-insiders-guide-to-a-hospital-stay-2018071814266]]>New blood test may someday help guide the best treatment for aggressive prostate cancerhttps://www.health.harvard.edu/blog/new-blood-test-may-someday-help-guide-the-best-treatment-for-aggressive-prostate-cancer-2018080114392https://hhp-blog.s3.amazonaws.com/2018/07/iStock-489113180.jpg2018-07-18 10:30:202018-07-18 14:30:20The introvert’s guide to social engagementhttps://www.health.harvard.edu/blog/the-introverts-guide-to-social-engagement-2018111415353https://hhp-blog.s3.amazonaws.com/2018/07/iStock-489113180.jpg2018-07-18 10:30:202018-07-18 14:30:20A practical guide to the Mediterranean diethttps://www.health.harvard.edu/blog/a-practical-guide-to-the-mediterranean-diet-2019032116194https://hhp-blog.s3.amazonaws.com/2018/07/iStock-489113180.jpg2018-07-18 10:30:202018-07-18 14:30:20Gene testing to guide antidepressant treatment: Has its time arrived?https://www.health.harvard.edu/blog/gene-testing-to-guide-antidepressant-treatment-has-its-time-arrived-2019100917964https://hhp-blog.s3.amazonaws.com/2018/07/iStock-489113180.jpg2018-07-18 10:30:202018-07-18 14:30:20Stay safe in (and on) the waterhttps://www.health.harvard.edu/blog/stay-safe-in-and-on-the-water-2017070712014https://hhp-blog.s3.amazonaws.com/2018/07/iStock-489113180.jpg2018-07-18 10:30:202018-07-18 14:30:20https://hhp-blog.s3.amazonaws.com/2018/07/iStock-489113180.jpgI’m so lonesome I could cryhttps://www.health.harvard.edu/blog/im-so-lonesome-i-could-cry-2018032113512
https://www.health.harvard.edu/blog/im-so-lonesome-i-could-cry-2018032113512#commentsWed, 21 Mar 2018 14:30:41 +0000https://www.health.harvard.edu/blog/?p=13512The health risks of loneliness and isolation have been known for some time, but more recently research has shown the specific effects in the brain. Finding ways to make connections with other people is the best “medicine” to alleviate the mental and physical effects of loneliness.

After only the opening chords and one or two bars of that haunting melody, you probably recognize the old song by Hank Williams — the one with the lyrics that express a feeling almost all of us have experienced:

Hear that lonesome whippoorwillHe sounds too blue to fly.The midnight train is whining low
I’m so lonesome I could cry.

Although the song captures a common feeling, we now know it is not just a feeling, but a condition that has a very real effect on the body, and as it turns out is also a public health problem — so much so that as the new year turned in Great Britain, the issues of loneliness and social isolation were added to a ministerial portfolio. A survey study there showed that hundreds of thousands of people had not spoken to a friend or relative in a month — that’s a lot of silence in your life.

Humans are social creatures. Among ourselves we form all kinds of complex alliances, affiliations, attachments, loves, and hates. If those connections break down, an individual risks health impacts throughout the body.

The health risks of loneliness

A brief list from recent research includes:

increased risk of cardiovascular disease

decreased cognitive and executive function (there is initial evidence of increased amyloid burden in the brains of the lonely)

as high as a 26% increase in the risk of premature death from all causes

decrease in the quality of sleep

increased chronic inflammation and decreased inflammatory control (linked to the risk of cognitive impairment and dementia)

decreased immune function leading to vulnerability to many types of disease

increased depressive symptoms

increased fearfulness of social situations (sometimes resulting in paranoia)

increased severity of strokes (with shortened survival)

and, as you would expect, an overall decrease in the subjective sense of well-being.

As early as 1988, an important overview of multiple studies documented that social isolation was a major risk factor for mortality, illness, and injury, and in fact was as significant a risk factor as smoking, obesity, or high blood pressure. The effects and prevalence of social isolation have been confirmed in good studies many times now, as well as in the work of advocacy groups such as the AARP. In a 2010 survey study, the AARP found that in the US, 35% of adults over the age of 45 were lonely, and isolation was getting worse — 56% of the lonely had fewer friends at the time of the survey than five years before. A study in 2012 found a higher percentage of lonely people — 40%. The AARP survey found (as have other studies) that loneliness was connected to poor health.

But it is only recently that mapping out the underlying neurobiology and neuroendocrinology has become possible, using new technologies.

The effects of loneliness on the brain

Here are a few ways in which loneliness shows up in the brain:

areas of the brain having to do with the perception of pain are activated

gray matter density decreases in an area of the brain related to social perception

areas of the brain having to do with “mentalization” (imagining other people’s minds) are decreased in activity

the brain (in the all-important amygdala, for example) shows increased activity, with decreased recovery in response to negative stimuli — as Lily Tomlin on Sesame Street said about anger, this is “bad weather in the brain.”

The endocrinology is also important

The HPA axis — the feedback system across the hypothalamus, pituitary, and adrenal glands — is impacted and results mainly through the dysregulation of stress hormones, and this is associated downstream with many negative health outcomes; oxytocin (the “social hormone”) function is apparently decreased; brain derived neurotrophic factor (BDNF), one of the most abundant background facilitators of neuronal plasticity and nerve health, is decreased; and allopregnanolone, an important health-positive neurosteroid in the brain, is also decreased.

If that song, and all the health impacts of loneliness (from the cardio to the neuro to the hormonal), strike close to home, what can a person do?

Understand that people are a medicine

Sigmund Freud, in a chapter on anxiety in his Introductory Lectures on Psychoanalysis, relates a lovely story about a young boy who was afraid of the dark, except when his aunt talked to him. The boy said, “When someone speaks, it gets lighter.”

So, people are anxiety relievers. And people are antidepressants, as well as blood pressure reducers (mostly). People, in general, are good for you. So, find ways to be around and be with people; let people accompany you on your travels through life.

Ways to do this are more common than you might think.

People from a distance: go to a library reading room to read the papers and take in the crowd.

People closer up: volunteer at a hospital, or a local food bank, or another organization that needs help.

People with engagement: join a congregation of worship; take up a hobby that you can share with others, such as a sport, or a game club (chess, mah-jongg, cards, Scrabble).

People with even more engagement: renew old friendships that may have withered on the vine; you will be surprised what a difference just having tea or coffee with an old friend regularly will make. The AARP found that having even one supportive relationship decreased perceived loneliness (and by implication, the health impact) from 76% for those with none to 36%.

If you feel introspective (Mark Twain said, “The worst loneliness is to not be comfortable with yourself”), seek out a therapist with whom you can think about your situation.

People are complicated. People can be difficult. But it is only within the complex and gratifying and sometimes challenging ecology of human relationships that we can truly thrive. See you at the coffee shop.

]]>https://www.health.harvard.edu/blog/im-so-lonesome-i-could-cry-2018032113512/feed413512https://www.facebook.com/sharer/sharer.php?u=https%3A%2F%2Fwww.health.harvard.edu%2Fblog%2Fim-so-lonesome-i-could-cry-2018032113512]]>Yoga could complement traditional treatment for depressionhttps://www.health.harvard.edu/blog/yoga-could-complement-traditional-treatment-for-depression-2017090712369https://hhp-blog.s3.amazonaws.com/2018/03/iStock-869452690.jpg2018-03-21 10:30:412018-03-21 14:30:41Yoga could slow the harmful effects of stress and inflammationhttps://www.health.harvard.edu/blog/yoga-could-slow-the-harmful-effects-of-stress-and-inflammation-2017101912588https://hhp-blog.s3.amazonaws.com/2018/03/iStock-869452690.jpg2018-03-21 10:30:412018-03-21 14:30:41Could medications contribute to dementia?https://www.health.harvard.edu/blog/could-medications-contribute-to-dementia-2018052313872https://hhp-blog.s3.amazonaws.com/2018/03/iStock-869452690.jpg2018-03-21 10:30:412018-03-21 14:30:41Could household disinfectants be making our children fat?https://www.health.harvard.edu/blog/could-household-disinfectants-be-making-our-children-fat-2018100314949https://hhp-blog.s3.amazonaws.com/2018/03/iStock-869452690.jpg2018-03-21 10:30:412018-03-21 14:30:41Why the wheelchair? Could it be gout?https://www.health.harvard.edu/blog/why-the-wheelchair-could-it-be-gout-2019032916308https://hhp-blog.s3.amazonaws.com/2018/03/iStock-869452690.jpg2018-03-21 10:30:412018-03-21 14:30:41https://hhp-blog.s3.amazonaws.com/2018/03/iStock-869452690.jpgActive mind/body, healthy mind/bodyhttps://www.health.harvard.edu/blog/active-mind-body-healthy-mind-body-2018022613327
https://www.health.harvard.edu/blog/active-mind-body-healthy-mind-body-2018022613327#commentsMon, 26 Feb 2018 15:30:48 +0000https://www.health.harvard.edu/blog/?p=13327Getting regular exercise is one of the best actions you can take to improve or maintain your overall health. Fitting exercise into your life is not as difficult as it might seem, but it does require some planning.

Spring is just around the corner and if you’re ready to reboot one of your New Year’s resolutions, here’s why exercise should be at the top of the list. Current medical research continues to robustly establish vigorous physical exercise as a major influence on overall health and well-being, in addition helping in the treatment of many diseases including depression, cardiovascular disease, diabetes, and arthritis. A recent study found that regular, intense exercise beneficially influenced the action of 400 genes — that’s right, 400 genes, a huge number — that produce proteins increasing the healthy functioning of mitochondria, the energy-producing machinery inside every cell. Exercise is synergistic with medicines and surgery. Developing, undertaking, and maintaining an exercise regimen is one of the best steps a person can take toward a self-actualized style of medical care.

An exercise “prescription”

We are a physician couple who have been physically active all our lives. We prescribe exercise regularly in our practices (one of us is a neurologist, the other a psychiatrist) and approach it in exactly the same way that we approach prescribing a medication, informing patients of dose and frequency benefits, possible side effects, and mechanisms of action. We describe a concrete regimen of exercise rather than simply saying, “exercise” and leaving it at that. Many patients don’t know how to get started, and specific details about using machines, weights, running, and other techniques prove valuable. Practical details are important, and we take time to answer any and all questions a patient might have. The physician-patient partnership around overall health goals is crucial. As partners, they can work together to include exercise as one tool among many to help achieve good health.

Follow-up is also key to encourage continued elaboration of goals, to educate about the interventions, and to support motivation. An exercise regimen is not static, and for best effect changes organically over time.

We have also found it is important to describe our own exercise experience, as a way of modeling what is possible.

Here’s how we make room for exercise

We have discovered many techniques that help us maintain our exercise routines in the face of the daily demands of busy lives. Here is a partial list.

On Sunday night, when you think about your week, schedule your exercise just as you plan for work, errands, and other commitments. It’s easier to stick with it when you have concretely planned time.

Mix it up. Plan different types of exercise to challenge different muscle groups, as research shows us this is the best way to stay in shape and develop endurance and muscle mass.

Don’t get bogged down if you don’t have a lot of time. Research has demonstrated that intense, short bursts of exercise can be as effective as a longer workout, perhaps more so.

Get your heart rate up, but watch it recover to baseline too. Wearing some type of heart rate monitor can be helpful.

Try something new. Winter is a great time to try cross-country skiing. In the summer, why not go for a kayak paddle? Everything physical that you do counts as exercise.

Consider a consult with a personal trainer. You don’t need to commit to the time or expense of regular meetings, but a one-time consult can be informative and motivating.

Keep an exercise journal, at least at the start. You will be surprised when you concretely see how much progress you are making (be sure to set goals).

Do remember to get an okay from your PCP before you start. And one last thing — it never fails to motivate us that exercise can decrease your risk of developing cognitive impairment. That thought has us lacing up our running shoes and heading out the door every time. Hope we see you out there.

In a new online course from Harvard Health Publishing, Starting to Exercise, today’s leading fitness instructors show you workouts that work…the exercises that will help you enjoy a healthier, more vigorous, and longer life. You can access Starting To Exercise on your smart phone, tablet, or desktop computer. With easy log-in and simple-to-navigate screens, this online course is designed for adults of all ages.